- Email: [email protected]
The relationship between patient education and glycaemic control in a South African township
p r i m a r y c a r e d i a b e t e s 1 ( 2 0 0 7 ) 87–91
available at www.sciencedirect.com
journal homepage: http://www.intl.elsevierhealth.com/journals/pcd/
The relationship between patient education and glycaemic control in a South African township Marloes van de Sande a,∗ , Hanneke Dippenaar b , Guy E.H.M. Rutten c a b c
Faculty of Medicine, Utrecht University, Utrecht, The Netherlands Department of Family Medicine, University of the Free State, Bloemfontein, South Africa University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: To investigate if there is a relationship between patients’ perceived diabetes edu-
Received 13 April 2007
cation and their glycaemic control.
Accepted 13 April 2007
Methods: Two hundred and forty-seven diabetic (both DM 1 and DM 2) patients who were treated for diabetes in a primary nurse led health care clinic in South Africa were analyzed. Patients were interviewed, and information was retrieved from the patients’ medical record.
Keywords:
Results: Fasting blood glucose levels were <7.0 mmol/l in 17.6% of the patients, 79.3% of the
Diabetes mellitus
patients had a BMI > 27 88.2% of the patients received information about diabetes, the major-
Glycaemic control
ity received information from the nurse. Patients with a higher educational level and patients
Diabetes education
who received education tended to have a better glycaemic control. (n.s.) Significantly more
Primary care
patients who received information had a good or acceptable FBG level (p = 0.03). The recorded prevalence of chronic complications was low. Conclusions: Glycaemic control was suboptimal in the big majority of patients. Education had a positive effect on glycaemic control, albeit not impressive. Also in South Africa poor health literacy should be taken into account in diabetes education. © 2007 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
The importance of glycaemic control in the prevention of microvascular complications has been confirmed in both types 1 and 2 diabetic patients [1,2]. To improve quality of care, information might be helpful on patient and treatment characteristics that are possibly associated with poor glucose levels. In previous studies a variety of factors such as body mass index, educational level, diabetes education, are identified that may influence the outcome of care, but results are conflicting [3–6]. To stimulate patients to have an active role in their glycaemic control, education of patients might be helpful [4,7,8]. On the short term the effects of patient education are good, but in the long run hardly any positive results
∗
between patient education and glycaemic control could be demonstrated [9]. To examine the true effect of patient education on glycaemic control, ideally a randomized controlled trial would be set up. Nevertheless, studying the relationship between education and glycaemic control could provide further insight in the value of diabetes patient education. It would be interesting to research the effect of patient education on glycaemic control in a less-developed country. Diabetes is an increasing health problem in these countries, were less money is available for diabetes care [10]. The aim of this study was to investigate if there is a relationship between patients perceived diabetes education and their glycaemic control in a primary health care clinic in South Africa.
Corresponding author. E-mail address: [email protected] (M. van de Sande). 1751-9918/$ – see front matter © 2007 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.pcd.2007.04.007
88
p r i m a r y c a r e d i a b e t e s 1 ( 2 0 0 7 ) 87–91
2.
Methods
2.1.
Setting and participants
The study was carried out at the Heidedal community health centre in Bloemfontein, South Africa, in July and August 2005. The clinic is a primary health care clinic, situated in an urban area. The patients who visit the clinic are mainly black and coloured; most of them are living in townships. An average 300 diabetic patients a month are seen in this clinic. These are both types 1 and 2 diabetes patients. The management of diabetes in the Heidedal community health centre is nurse-led, with a general practitioner on consultation basis. Patients with fasting blood glucose level <12 mmol/l, and a diastolic blood pressure <100 mmHg are requested to come every 4 months. Patients with a fasting blood glucose level ≥12 mmol/l and/or a diastolic blood pressure ≥100 mmHg are requested to attend each month. All patients provided written informed consent. The study was approved by the medical-ethical committee of the University of the Free State.
2.2.
Design and patients
The criterion to be included in the study was treatment for diabetes mellitus in primary care. Information was obtained by interviewing the patients and by retrieving the patients’ medical record. The interview was done with a standardized questionnaire. The patients were interviewed in the Heidedal clinic after they were seen by a specialized diabetes nurse for control. All the patients were interviewed by the same person (MvdS). The interview contained 21 questions about sociodemographic and disease related factors (age, educational level, marital status, duration of diabetes, diabetes related disorders and complications), lifestyle parameters (including smoking, physical activity), and patient education. The medical records were searched for clinical parameters (fasting blood glucose, body mass index, blood pressure), factors related to treatment processes (actual treatment, number of visits for diabetes in the past 12 months) diabetes related complications and cardiovascular risk factors.
2.3.
Variables
With regards to education the patients were asked if they had received any information about diabetes and from whom they received that information. The questions: ‘do you think exercise has influence on diabetes’, ‘do you think body weight has influence on diabetes’, and ‘do you think nutrition has influence on diabetes’ were asked, they could be answered with ‘yes’, ‘no’ or ‘do not know’. Glycaemic control was defined by the fasting blood glucose level (FBG). Categories of fasting blood glucose were good <7.0; acceptable ≥7.0 and ≤8.0; poor >8.0 and ≤12.0; very poor >12.0 mmol/l. Fasting blood glucose was measured in capillary blood (finger prick), with a Glucotrend 2 glucose meter and Accu-check active test strips.
Blood pressures were measured with a PMah sphygmomanometer. The Korotkoff sound V was taken as the diastolic blood pressure. Hypertension was considered to be present if the patient was being treated with antihypertensive drugs and/or if the actual blood pressure was >160/95 mmHg. Blood pressure was categorized as: good <140/90; acceptable ≥140/90 and ≤160/95; poor >60/95. Body mass index (BMI) was calculated as the weight divided by the square of the height. BMI was categorized as: good <25; acceptable ≥25 and ≤27; poor >27 and ≤33 and very poor >33 kg/m2 . Proteinuria was measured with urine dipsticks: Uricheck 10. Microproteinuria measured on three or more successive visits was considered as proteinuria. Information about the lipid status was not available. Smoking was defined as yes/no. Physical activity was operationalized as the sum of hours per day spent on household activities, walking, cycling, or sports. Level of education was categorized into two main groups on the basis of education received (up to standard 7 or standard 8 and above). As the number of patients with tertiary education was relatively small, they were combined with those that had received secondary education. The medical records were scrutinized for the following diabetes related complications: retinopathy, nephropathy, peripheral neuropathy, cardiovascular morbidity including angina pectoris, myocardial infarction, heart failure, cerebrovascular accidents, transient ischaemic attacks and intermittent claudication/peripheral artery disease.
2.4.
Statistical analysis
Data analyses were performed with Microsoft Excel 2002. Means are expressed with standard deviation. The associations between categories of glycaemic control, number of diabetes related complications and patient education were measured with the Chi-square test. Pearson’s correlation coefficients were used to examine the relationship between numerical variables. A p value of less than 0.05 was considered statistically significant.
3.
Results
A total of 258 patients were interviewed, 11 were excluded because of incomplete data. Failure to interview all the patients who visited the clinic was because of refusal to participate in the study. About 20% of the patients visited the clinic more than one time during our study, these patients were interviewed once. The mean age of all included patients was 58.2 (S.D. 10.9), ranging from 30 until 85 years; 25.2 of the patients were male. The duration of diabetes ranged from 0 until 44 years, with a mean of 7.7 years (S.D. 6.6). The majority was non-insulin treated, 19.1% was insulin treated. Glycaemic control, according to FBG category was good in 17.6% of all patients and acceptable in 9.8% of all patients. Hypertension was present in 91.1% of the patients. In 34.2% of patients the blood pressure was categorized as poor.
89
p r i m a r y c a r e d i a b e t e s 1 ( 2 0 0 7 ) 87–91
Table 2 – Diabetes education
Table 1 – Patient characteristics (N = 247) Age (years) Male Educational level ≤standard 7 ≥standard 8
58.2 (10.9) 25.2
Living with a partner Duration of diabetes (years) Actual smoking Actual physical exercise Physical exercise (h/day)
44.1 7.7 (6.6) 14.6 89.4 2.5 (1.9)
Treatment Diet only OHAs Insulin + OHAs Insulin
1.2 79.7 1.2 17.9
Number of visits in the past 12 months Fasting blood glucose (mmol/l)a Good/acceptable/poor/very poor BMI (kg/m2 )b Good/acceptable/poor/very poor Hypertension
72.7 27.3
6.8 (2.5) 11.3 (4.4) 17.6/9.8/30.2/42.5 33.4 (7.1) 10.0/10.8/32.0/47.3
15.6/50.2/34.2
Diabetes related complications registered None/one/≥two
48.4/50/1.6 11.4 11.4 27.6 4.5 0.0 2.0 3.3 2.0 8.1
Data are percentages, unless otherwise indicated. Between parentheses: S.D. FBG: fasting blood glucose; BMI: body mass index; OHA: oral hypoglycemic agent. a
b
c
Received information
88.2
Information from (more than one answer possible) Nurse Doctor Dietician Pamphlet Family Other
80.5 24.4 7.3 32.1 4.1 2.4
Yes, physical exercise has influence on diabetes Yes, body weight has influence on diabetes Yes, nutrition has influence on diabetes Answersa No answer ‘yes’ One answer ‘yes’ Two answers ‘yes’ Three answers ‘yes’ a
91.1
Blood pressurec Good/acceptable/poor
Retinopathy Proteinuria Peripheral neuropathy Angina pectoris Myocard infarction Heart failure Cerebrovascular accident Transient ischemic attack Intermittend claudication/peripheral artery disease
Percentage of patients
FBG; good <7.0; acceptable ≥7.0 and ≤8.0; poor >8.0 and ≤12.0; very poor >12.0 mmol/l. BMI; good <25; acceptable ≥25 and ≤27; poor >27 and ≤33 and very poor >33 kg/m2 . Blood pressure; good <140/90; acceptable ≥140/90 and ≤160/90; poor >160/95 mm/Hg.
83.3 54.9 86.6
6.5 11.4 32.9 49.2
Answers on the questions: ‘do you think exercise has influence on diabetes?’, ‘do you think body weight has influence on diabetes?’, ‘do you think nutrition has influence on diabetes?’.
3.1.
Diabetes education
Ninety percent of the patients received information about diabetes and 80% received information from a nurse. About 50% of the patients answered yes on the three questions about diabetes education asked in the interview (Table 2).
3.2. Association between patient education and glycaemic control Patients with an educational level ≤8, patients who received information about diabetes and patients who received information from a nurse had better fasting blood glucose levels, but this difference was not large enough either to be statistically significant (Table 3). When calculations were done with only two categories of FBG (≤8 and >8 mmol/l), 29.6% of the patients who received information had a FBG ≤ 8 mmol/l versus 10.3% of the patients who received no information (p = 0.03). A 30.5% of the patients who received information from a nurse had a FBG ≤ 8 mmol/l versus 14.5% of the patients who received no information from a nurse (p = 0.03) (data not shown).
3.3. Correlation between patient and disease characteristics and fasting blood glucose The mean BMI was 33.4 kg/m2 (S.D. 7.1), with a minimum of 17.6 kg/m2 and a maximum of 58.4 kg/m2 . Obesity (BMI > 27.0) was present in 79.3% of all subjects. Furthermore 14.6% of all patients were smokers and 82.9% of the patients had daily exercise. In 48.4% of the patients there were no diabetes related complications registered. Peripheral neuropathy was the most frequently registered complication; it was registered in 27.7% of the patients (Table 1).
Patients with a higher number of visits in the past 12 months had a higher FBG level (Pearson’s r = 0.29; calculated with continue FBG levels). No other correlation was found (data not shown).
4.
Discussion
Only 18% of the patients had a fasting blood glucose level ≤7 mmol/l, the target for good control. Ninety-one percent
90
p r i m a r y c a r e d i a b e t e s 1 ( 2 0 0 7 ) 87–91
Table 3 – Association between education and fasting blood glucose Fasting blood glucose:
Good (%)
Acceptable (%)
Poor (%)
Very poor (%)
p-Value*
Received information Received no information
18.5 10.3
11.1 0.0
28.2 44.8
42.1 44.8
0.09
Exercise has influence on diabetes Exercise has no influence on diabetes or do not know
18.1 14.6
11.3 2.4
28.4 39.0
42.2 43.9
0.24
Weight has influence on diabetes Weight has no influence on diabetes or do not know
20.0 14.6
11.1 8.2
25.9 34.5
43.0 41.8
0.33
Nutrition has influence on diabetes Nutrition has no influence on diabetes or do not know
16.5 24.2
10.4 6.1
28.8 39.4
44.3 30.3
0.27
Information received from nurse No information received from nurse
18.8 12.5
11.7 2.1
27.4 41.7
42.1 43.8
0.07
Information received from doctor No information received from doctor
13.3 18.9
10.0 9.7
30.0 30.3
46.7 41.1
0.77
Information received from dietician No information received from dietician
16.7 17.6
22.2 8.8
22.2 30.8
38.9 42.7
0.32
Information received from pamflet No information received from pamphlet
15.2 18.7
10.1 9.6
29.1 30.7
45.6 41.0
0.87
Information received form other sources No information received from other sources
12.5 17.9
06.3 10.0
18.8 31.0
62.5 41.1
0.42
Education ≤ standard 7 Education ≥ standard 8
18.3 16.7
6.9 16.7
32.6 22.7
42.3 43.9
0.09
Percentages are row percentages. ∗
p-Value calculated with four categories of fasting blood glucose level.
of the patients had hypertension, 79% was obese. In a study carried out in public health sector in a rural district in KwaZulu-Natal (South Africa), acceptable glycaemic control (defined as HbA1c < 2% above normal population range) was found in only 16% of patients. Hypertension (blood pressure ≥160/95 mmHg and/or prescribed antihypertensive medication) was present in 65% of patients, and severe obesity (BMI > 33 kg/m2 ) in 37% of patients [11]. In patients attending a black peri-urban community clinic the target values of HbA1c < 7% were achieved in only 20% of patients. Obesity (BMI ≥ 25 kg/m2 for females and BMI ≥ 27 kg/m2 for males) was present in 79% of the patients [12]. In black African patients at the primary care level in the public sector in Cape Town (South Africa); acceptable glycaemic control (defined as HbA1c < 2% above normal population range) was found in 49% of patients, the mean BMI in men was 25 (±4), in women 33 (±6). Hypertension (blood pressure ≥160/95 mmHg and/or prescribed antihypertensive medication) was present in 52% of patients. A high prevalence of suboptimal glycaemic and blood pressure control was found as well [13]. The prevalence of registered chronic complications in our study was low compared with the above mentioned studies, in which retinopathy was present in 40% or even 55% of the patients [11,13]. It is likely that many complications are not recognized or diagnosed, as was the case in the other cited studies. Treatment in this clinic was according a protocol based on the clinical practice recommendations of the American Diabetes Association. These guidelines are similar with guidelines used in the United States and Europe. It is the question
however, if implementation of the guidelines and patient compliance is comparable between these countries [6,14]. Remarkable is that about 75% of the included patients in our study were female; this excess of females is comparable with the above-mentioned studies. This male–female ratio is a reflection of the patients attending for chronic medical care in South Africa [15]. The number of patients who visited the clinic during our study was low compared with the average number of patients visits; an explanation could be the cold weather and transportation problems. Patients who are living more far away from the clinic could therefore be less represented in our study. We did not recorded employment. It could be that patients with a job are less represented because they did not have the opportunity to visit the clinic. It was not possible to interview all the patients who visited the clinic. Some patients did not have time to wait for the interview and refused to participate in the study. It is possible that these patients are less interested in their disease and have less knowledge about diabetes. In our study only five questions about education were asked. Three of them were closed questions, and it is possible that patients had the tendency to say ‘yes’ because of the nature of the question. The answers of the patients could have been related to themselves instead of related to diabetes mellitus in general. These five questions are not enough to know exactly how much knowledge patients have about their disease, how much information they received and from whom. These questions gave us information about how much knowledge patients have about diabetes more than information about the education they received. However, these five questions were thought to be sufficient to get an impression
p r i m a r y c a r e d i a b e t e s 1 ( 2 0 0 7 ) 87–91
about patients’ perceived diabetes education and although they may have been blunt, they were also very practicable. In this study it was not possible to measure the percentage of glycosylated haemoglobin and the lipid status. The majority of the patients in our study had received information about diabetes; 80% received information from the nurse. About half of the patients knew that weight, nutrition and physical activity have influence on their diabetes mellitus. Significantly more patients who received information fell in the best two of glucose categories. Nevertheless, it seems that although patients know how they should live with their disease, implementation of the received information remains doubtful. In a study that researched the barriers to dietary compliance of black South African type 2 diabetic patients, attending primary health-care services in urban and rural areas, the following factors were identified as contributors to poor glycaemic control: lack of knowledge regarding the disease; inadequate and inaccurate dietary counselling; and poor compliance with dietary advice given. It was suggested that nutrition therapy for black patients is unsuccessful when the diet prescription does not relate to the patients cultural environment and economic situation and is presented in ways that are difficult for low-literacy patients to understand and implement [16]. Health literacy is a measure of patients ability to read, comprehend and act on medical instructions. Poor health literacy is common among patients who have low educational attainment and among patients with chronic medical conditions, such as type 2 diabetes [17,18]. In a study that examined the association between health literacy and diabetes outcomes among type 2 diabetes in San Francisco (United States); inadequate health literacy was associated with worse glycaemic control [19]. Also in our study patients with low educational level tended to fall in the worse diabetes regulation categories. To conclude, diabetes is not only a major burden in the developed world; it is also an increasing health problem in less-developed countries. Although education could be a tool to achieve better glycaemic control, it is important to understand that education should be adjusted to patients’ literacy, cultural environment and economic status [16,18,19]. This conclusion holds for the diabetes population in a primary care health clinic in a South African township.
[2]
[3]
[4]
[5]
[6] [7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
Conflict of interest statement There were no conflicts of interest.
[16]
Acknowledgment We would like to thank the staff of the Heidedal clinic in Bloemfontein for their cooperation and support.
[17]
[18]
references
[1] The Diabetes Control Complications Trial Research Group, The effect of intensive treament of diabetes on the development and progression of long-term complications in
[19]
91
insuline-dependent diabetes mellitus, N. Engl. J. Med. 329 (1993) 977–986. UK Prosprective Diabetes Group, Intensive blood glucose control with sulphonurea or insulin compared with convential treatment and risks of complications in patients with type 2 diabetes (UKPDS 33), Lancet 352 (1998) 837–853. A.N. Goudswaard, R.P. Stolk, P. Zuithoff, G.E.H.M. Rutten, Patients characteristics do not predict poor glycaemic control in type 2 diabetes patients treated in primary care, Eur. J. Epidemiol. 19 (2004) 541–545. W.B. Chan, J.C.N. Chan, C.C. Chow, et al., Glycaemic control in type 2 diabetes: the impact of body weight, b-cell function and patient education, Q. J. Med. 93 (2000) 183–190. C.S. Blaum, L. Velez, R.G. Hiss, J.B. Halter, Characteristics related to poor glycemic control in NIDDM patients in community practice, Diabetes Care 20 (1997) 7–11. G. Rutten, Editorial, Diabetes patient education: time for a new era, Diabetic Med. 22 (2005) 671–673. I.J.M. van den Arend, R.P. Stolk, G.E.H.M. Rutten, G.J.P. Schrijvers, Education integrated into structured general practice care for Type 2 diabetic patients results in sustained improvement of disease knowledge and self-care, Diabetic Med. 17 (2000) 190–197. T.L. Gary, J.M. Genkinger, E.G. Guallor, et al., Meta-analysis of randomized educational and behavioral interventions in Type 2 diabetes, Diabetes Educ. 29 (2003) 488–501. A.N. Goudswaard, R.P. Stolk, N.P.A. Zuithoff, et al., Long-term effect of self-manegement education for patients with Type 2 diabetes taking maximal oral hypoglycaemic therapy: a randomized trial in primary care, Diabetic Med. 21 (2004) 491–496. S. Wild, G. Roglic, A. Green, et al., Global prevalence of diabetes: estimates for the year 2000 and projections for 2030, Diabetes Care 27 (2004) 1047–1053. A.P. Rotchford, K.M. Rotchford, Diabetes in Rural South Africa—an assessment of care and complications, S. Afr. Med. J. 92 (2002) 536–541. R.T. Erasmus, E. Blanco Blanco, A.B. Okesina, et al., Assessment of glycaemic control in stable type 2 black South African diabetics attending a peri-urban clinic, Postgrad. Med. J. 75 (1999) 603–606. N.S. Levitt, D. Bradshaw, M.F. Zwarenstein, et al., Audit of Public Sector Primary Diabetes Care in Cape Town, South Africa: high prevalence of complications, uncontrolled hyperglycaemia, and hypertension, Diabetic Med. 14 (1997) 1073–1077. M. Haque, S. Hayden Emerson, C.R. Dennison, et al., Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town, S. Afr. Med. J. 95 (2005) 798–802. R. Coleman, G. Gill, D. Wilkinson, Noncommunicable disease management in resource-poor settings: a primary care model from rural South Africa, Bull. World Health Organ. 76 (1998) 633–640. G. Nthangeni, N.P. Steyn, M. Alberts, K. Steyn, et al., Dietary intake and barriers to dietary compliance in black type 2 diabetic patients attending primary health-care services, Public Health Nutr. 5 (2002) 329–338. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, Health literacy: report of the council of scientific affairs, JAMA 281 (1999) 552–555. M.V. Williams, D.W. Baker, R.M. Parker, J.R. Nurss, Relationship of functional health literacy to patients knowledge of their chronic disease: a study of patients with hypertension and diabetes, Arch. Intern. Med. 158 (1998) 166–172. D. Schillinger, K. Grumbach, J. Piette, et al., Associations of health literacy with diabetes outcomes, JAMA 288 (2002) 475–482.
available at www.sciencedirect.com
journal homepage: http://www.intl.elsevierhealth.com/journals/pcd/
The relationship between patient education and glycaemic control in a South African township Marloes van de Sande a,∗ , Hanneke Dippenaar b , Guy E.H.M. Rutten c a b c
Faculty of Medicine, Utrecht University, Utrecht, The Netherlands Department of Family Medicine, University of the Free State, Bloemfontein, South Africa University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: To investigate if there is a relationship between patients’ perceived diabetes edu-
Received 13 April 2007
cation and their glycaemic control.
Accepted 13 April 2007
Methods: Two hundred and forty-seven diabetic (both DM 1 and DM 2) patients who were treated for diabetes in a primary nurse led health care clinic in South Africa were analyzed. Patients were interviewed, and information was retrieved from the patients’ medical record.
Keywords:
Results: Fasting blood glucose levels were <7.0 mmol/l in 17.6% of the patients, 79.3% of the
Diabetes mellitus
patients had a BMI > 27 88.2% of the patients received information about diabetes, the major-
Glycaemic control
ity received information from the nurse. Patients with a higher educational level and patients
Diabetes education
who received education tended to have a better glycaemic control. (n.s.) Significantly more
Primary care
patients who received information had a good or acceptable FBG level (p = 0.03). The recorded prevalence of chronic complications was low. Conclusions: Glycaemic control was suboptimal in the big majority of patients. Education had a positive effect on glycaemic control, albeit not impressive. Also in South Africa poor health literacy should be taken into account in diabetes education. © 2007 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
The importance of glycaemic control in the prevention of microvascular complications has been confirmed in both types 1 and 2 diabetic patients [1,2]. To improve quality of care, information might be helpful on patient and treatment characteristics that are possibly associated with poor glucose levels. In previous studies a variety of factors such as body mass index, educational level, diabetes education, are identified that may influence the outcome of care, but results are conflicting [3–6]. To stimulate patients to have an active role in their glycaemic control, education of patients might be helpful [4,7,8]. On the short term the effects of patient education are good, but in the long run hardly any positive results
∗
between patient education and glycaemic control could be demonstrated [9]. To examine the true effect of patient education on glycaemic control, ideally a randomized controlled trial would be set up. Nevertheless, studying the relationship between education and glycaemic control could provide further insight in the value of diabetes patient education. It would be interesting to research the effect of patient education on glycaemic control in a less-developed country. Diabetes is an increasing health problem in these countries, were less money is available for diabetes care [10]. The aim of this study was to investigate if there is a relationship between patients perceived diabetes education and their glycaemic control in a primary health care clinic in South Africa.
Corresponding author. E-mail address: [email protected] (M. van de Sande). 1751-9918/$ – see front matter © 2007 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.pcd.2007.04.007
88
p r i m a r y c a r e d i a b e t e s 1 ( 2 0 0 7 ) 87–91
2.
Methods
2.1.
Setting and participants
The study was carried out at the Heidedal community health centre in Bloemfontein, South Africa, in July and August 2005. The clinic is a primary health care clinic, situated in an urban area. The patients who visit the clinic are mainly black and coloured; most of them are living in townships. An average 300 diabetic patients a month are seen in this clinic. These are both types 1 and 2 diabetes patients. The management of diabetes in the Heidedal community health centre is nurse-led, with a general practitioner on consultation basis. Patients with fasting blood glucose level <12 mmol/l, and a diastolic blood pressure <100 mmHg are requested to come every 4 months. Patients with a fasting blood glucose level ≥12 mmol/l and/or a diastolic blood pressure ≥100 mmHg are requested to attend each month. All patients provided written informed consent. The study was approved by the medical-ethical committee of the University of the Free State.
2.2.
Design and patients
The criterion to be included in the study was treatment for diabetes mellitus in primary care. Information was obtained by interviewing the patients and by retrieving the patients’ medical record. The interview was done with a standardized questionnaire. The patients were interviewed in the Heidedal clinic after they were seen by a specialized diabetes nurse for control. All the patients were interviewed by the same person (MvdS). The interview contained 21 questions about sociodemographic and disease related factors (age, educational level, marital status, duration of diabetes, diabetes related disorders and complications), lifestyle parameters (including smoking, physical activity), and patient education. The medical records were searched for clinical parameters (fasting blood glucose, body mass index, blood pressure), factors related to treatment processes (actual treatment, number of visits for diabetes in the past 12 months) diabetes related complications and cardiovascular risk factors.
2.3.
Variables
With regards to education the patients were asked if they had received any information about diabetes and from whom they received that information. The questions: ‘do you think exercise has influence on diabetes’, ‘do you think body weight has influence on diabetes’, and ‘do you think nutrition has influence on diabetes’ were asked, they could be answered with ‘yes’, ‘no’ or ‘do not know’. Glycaemic control was defined by the fasting blood glucose level (FBG). Categories of fasting blood glucose were good <7.0; acceptable ≥7.0 and ≤8.0; poor >8.0 and ≤12.0; very poor >12.0 mmol/l. Fasting blood glucose was measured in capillary blood (finger prick), with a Glucotrend 2 glucose meter and Accu-check active test strips.
Blood pressures were measured with a PMah sphygmomanometer. The Korotkoff sound V was taken as the diastolic blood pressure. Hypertension was considered to be present if the patient was being treated with antihypertensive drugs and/or if the actual blood pressure was >160/95 mmHg. Blood pressure was categorized as: good <140/90; acceptable ≥140/90 and ≤160/95; poor >60/95. Body mass index (BMI) was calculated as the weight divided by the square of the height. BMI was categorized as: good <25; acceptable ≥25 and ≤27; poor >27 and ≤33 and very poor >33 kg/m2 . Proteinuria was measured with urine dipsticks: Uricheck 10. Microproteinuria measured on three or more successive visits was considered as proteinuria. Information about the lipid status was not available. Smoking was defined as yes/no. Physical activity was operationalized as the sum of hours per day spent on household activities, walking, cycling, or sports. Level of education was categorized into two main groups on the basis of education received (up to standard 7 or standard 8 and above). As the number of patients with tertiary education was relatively small, they were combined with those that had received secondary education. The medical records were scrutinized for the following diabetes related complications: retinopathy, nephropathy, peripheral neuropathy, cardiovascular morbidity including angina pectoris, myocardial infarction, heart failure, cerebrovascular accidents, transient ischaemic attacks and intermittent claudication/peripheral artery disease.
2.4.
Statistical analysis
Data analyses were performed with Microsoft Excel 2002. Means are expressed with standard deviation. The associations between categories of glycaemic control, number of diabetes related complications and patient education were measured with the Chi-square test. Pearson’s correlation coefficients were used to examine the relationship between numerical variables. A p value of less than 0.05 was considered statistically significant.
3.
Results
A total of 258 patients were interviewed, 11 were excluded because of incomplete data. Failure to interview all the patients who visited the clinic was because of refusal to participate in the study. About 20% of the patients visited the clinic more than one time during our study, these patients were interviewed once. The mean age of all included patients was 58.2 (S.D. 10.9), ranging from 30 until 85 years; 25.2 of the patients were male. The duration of diabetes ranged from 0 until 44 years, with a mean of 7.7 years (S.D. 6.6). The majority was non-insulin treated, 19.1% was insulin treated. Glycaemic control, according to FBG category was good in 17.6% of all patients and acceptable in 9.8% of all patients. Hypertension was present in 91.1% of the patients. In 34.2% of patients the blood pressure was categorized as poor.
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Table 2 – Diabetes education
Table 1 – Patient characteristics (N = 247) Age (years) Male Educational level ≤standard 7 ≥standard 8
58.2 (10.9) 25.2
Living with a partner Duration of diabetes (years) Actual smoking Actual physical exercise Physical exercise (h/day)
44.1 7.7 (6.6) 14.6 89.4 2.5 (1.9)
Treatment Diet only OHAs Insulin + OHAs Insulin
1.2 79.7 1.2 17.9
Number of visits in the past 12 months Fasting blood glucose (mmol/l)a Good/acceptable/poor/very poor BMI (kg/m2 )b Good/acceptable/poor/very poor Hypertension
72.7 27.3
6.8 (2.5) 11.3 (4.4) 17.6/9.8/30.2/42.5 33.4 (7.1) 10.0/10.8/32.0/47.3
15.6/50.2/34.2
Diabetes related complications registered None/one/≥two
48.4/50/1.6 11.4 11.4 27.6 4.5 0.0 2.0 3.3 2.0 8.1
Data are percentages, unless otherwise indicated. Between parentheses: S.D. FBG: fasting blood glucose; BMI: body mass index; OHA: oral hypoglycemic agent. a
b
c
Received information
88.2
Information from (more than one answer possible) Nurse Doctor Dietician Pamphlet Family Other
80.5 24.4 7.3 32.1 4.1 2.4
Yes, physical exercise has influence on diabetes Yes, body weight has influence on diabetes Yes, nutrition has influence on diabetes Answersa No answer ‘yes’ One answer ‘yes’ Two answers ‘yes’ Three answers ‘yes’ a
91.1
Blood pressurec Good/acceptable/poor
Retinopathy Proteinuria Peripheral neuropathy Angina pectoris Myocard infarction Heart failure Cerebrovascular accident Transient ischemic attack Intermittend claudication/peripheral artery disease
Percentage of patients
FBG; good <7.0; acceptable ≥7.0 and ≤8.0; poor >8.0 and ≤12.0; very poor >12.0 mmol/l. BMI; good <25; acceptable ≥25 and ≤27; poor >27 and ≤33 and very poor >33 kg/m2 . Blood pressure; good <140/90; acceptable ≥140/90 and ≤160/90; poor >160/95 mm/Hg.
83.3 54.9 86.6
6.5 11.4 32.9 49.2
Answers on the questions: ‘do you think exercise has influence on diabetes?’, ‘do you think body weight has influence on diabetes?’, ‘do you think nutrition has influence on diabetes?’.
3.1.
Diabetes education
Ninety percent of the patients received information about diabetes and 80% received information from a nurse. About 50% of the patients answered yes on the three questions about diabetes education asked in the interview (Table 2).
3.2. Association between patient education and glycaemic control Patients with an educational level ≤8, patients who received information about diabetes and patients who received information from a nurse had better fasting blood glucose levels, but this difference was not large enough either to be statistically significant (Table 3). When calculations were done with only two categories of FBG (≤8 and >8 mmol/l), 29.6% of the patients who received information had a FBG ≤ 8 mmol/l versus 10.3% of the patients who received no information (p = 0.03). A 30.5% of the patients who received information from a nurse had a FBG ≤ 8 mmol/l versus 14.5% of the patients who received no information from a nurse (p = 0.03) (data not shown).
3.3. Correlation between patient and disease characteristics and fasting blood glucose The mean BMI was 33.4 kg/m2 (S.D. 7.1), with a minimum of 17.6 kg/m2 and a maximum of 58.4 kg/m2 . Obesity (BMI > 27.0) was present in 79.3% of all subjects. Furthermore 14.6% of all patients were smokers and 82.9% of the patients had daily exercise. In 48.4% of the patients there were no diabetes related complications registered. Peripheral neuropathy was the most frequently registered complication; it was registered in 27.7% of the patients (Table 1).
Patients with a higher number of visits in the past 12 months had a higher FBG level (Pearson’s r = 0.29; calculated with continue FBG levels). No other correlation was found (data not shown).
4.
Discussion
Only 18% of the patients had a fasting blood glucose level ≤7 mmol/l, the target for good control. Ninety-one percent
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Table 3 – Association between education and fasting blood glucose Fasting blood glucose:
Good (%)
Acceptable (%)
Poor (%)
Very poor (%)
p-Value*
Received information Received no information
18.5 10.3
11.1 0.0
28.2 44.8
42.1 44.8
0.09
Exercise has influence on diabetes Exercise has no influence on diabetes or do not know
18.1 14.6
11.3 2.4
28.4 39.0
42.2 43.9
0.24
Weight has influence on diabetes Weight has no influence on diabetes or do not know
20.0 14.6
11.1 8.2
25.9 34.5
43.0 41.8
0.33
Nutrition has influence on diabetes Nutrition has no influence on diabetes or do not know
16.5 24.2
10.4 6.1
28.8 39.4
44.3 30.3
0.27
Information received from nurse No information received from nurse
18.8 12.5
11.7 2.1
27.4 41.7
42.1 43.8
0.07
Information received from doctor No information received from doctor
13.3 18.9
10.0 9.7
30.0 30.3
46.7 41.1
0.77
Information received from dietician No information received from dietician
16.7 17.6
22.2 8.8
22.2 30.8
38.9 42.7
0.32
Information received from pamflet No information received from pamphlet
15.2 18.7
10.1 9.6
29.1 30.7
45.6 41.0
0.87
Information received form other sources No information received from other sources
12.5 17.9
06.3 10.0
18.8 31.0
62.5 41.1
0.42
Education ≤ standard 7 Education ≥ standard 8
18.3 16.7
6.9 16.7
32.6 22.7
42.3 43.9
0.09
Percentages are row percentages. ∗
p-Value calculated with four categories of fasting blood glucose level.
of the patients had hypertension, 79% was obese. In a study carried out in public health sector in a rural district in KwaZulu-Natal (South Africa), acceptable glycaemic control (defined as HbA1c < 2% above normal population range) was found in only 16% of patients. Hypertension (blood pressure ≥160/95 mmHg and/or prescribed antihypertensive medication) was present in 65% of patients, and severe obesity (BMI > 33 kg/m2 ) in 37% of patients [11]. In patients attending a black peri-urban community clinic the target values of HbA1c < 7% were achieved in only 20% of patients. Obesity (BMI ≥ 25 kg/m2 for females and BMI ≥ 27 kg/m2 for males) was present in 79% of the patients [12]. In black African patients at the primary care level in the public sector in Cape Town (South Africa); acceptable glycaemic control (defined as HbA1c < 2% above normal population range) was found in 49% of patients, the mean BMI in men was 25 (±4), in women 33 (±6). Hypertension (blood pressure ≥160/95 mmHg and/or prescribed antihypertensive medication) was present in 52% of patients. A high prevalence of suboptimal glycaemic and blood pressure control was found as well [13]. The prevalence of registered chronic complications in our study was low compared with the above mentioned studies, in which retinopathy was present in 40% or even 55% of the patients [11,13]. It is likely that many complications are not recognized or diagnosed, as was the case in the other cited studies. Treatment in this clinic was according a protocol based on the clinical practice recommendations of the American Diabetes Association. These guidelines are similar with guidelines used in the United States and Europe. It is the question
however, if implementation of the guidelines and patient compliance is comparable between these countries [6,14]. Remarkable is that about 75% of the included patients in our study were female; this excess of females is comparable with the above-mentioned studies. This male–female ratio is a reflection of the patients attending for chronic medical care in South Africa [15]. The number of patients who visited the clinic during our study was low compared with the average number of patients visits; an explanation could be the cold weather and transportation problems. Patients who are living more far away from the clinic could therefore be less represented in our study. We did not recorded employment. It could be that patients with a job are less represented because they did not have the opportunity to visit the clinic. It was not possible to interview all the patients who visited the clinic. Some patients did not have time to wait for the interview and refused to participate in the study. It is possible that these patients are less interested in their disease and have less knowledge about diabetes. In our study only five questions about education were asked. Three of them were closed questions, and it is possible that patients had the tendency to say ‘yes’ because of the nature of the question. The answers of the patients could have been related to themselves instead of related to diabetes mellitus in general. These five questions are not enough to know exactly how much knowledge patients have about their disease, how much information they received and from whom. These questions gave us information about how much knowledge patients have about diabetes more than information about the education they received. However, these five questions were thought to be sufficient to get an impression
p r i m a r y c a r e d i a b e t e s 1 ( 2 0 0 7 ) 87–91
about patients’ perceived diabetes education and although they may have been blunt, they were also very practicable. In this study it was not possible to measure the percentage of glycosylated haemoglobin and the lipid status. The majority of the patients in our study had received information about diabetes; 80% received information from the nurse. About half of the patients knew that weight, nutrition and physical activity have influence on their diabetes mellitus. Significantly more patients who received information fell in the best two of glucose categories. Nevertheless, it seems that although patients know how they should live with their disease, implementation of the received information remains doubtful. In a study that researched the barriers to dietary compliance of black South African type 2 diabetic patients, attending primary health-care services in urban and rural areas, the following factors were identified as contributors to poor glycaemic control: lack of knowledge regarding the disease; inadequate and inaccurate dietary counselling; and poor compliance with dietary advice given. It was suggested that nutrition therapy for black patients is unsuccessful when the diet prescription does not relate to the patients cultural environment and economic situation and is presented in ways that are difficult for low-literacy patients to understand and implement [16]. Health literacy is a measure of patients ability to read, comprehend and act on medical instructions. Poor health literacy is common among patients who have low educational attainment and among patients with chronic medical conditions, such as type 2 diabetes [17,18]. In a study that examined the association between health literacy and diabetes outcomes among type 2 diabetes in San Francisco (United States); inadequate health literacy was associated with worse glycaemic control [19]. Also in our study patients with low educational level tended to fall in the worse diabetes regulation categories. To conclude, diabetes is not only a major burden in the developed world; it is also an increasing health problem in less-developed countries. Although education could be a tool to achieve better glycaemic control, it is important to understand that education should be adjusted to patients’ literacy, cultural environment and economic status [16,18,19]. This conclusion holds for the diabetes population in a primary care health clinic in a South African township.
[2]
[3]
[4]
[5]
[6] [7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
Conflict of interest statement There were no conflicts of interest.
[16]
Acknowledgment We would like to thank the staff of the Heidedal clinic in Bloemfontein for their cooperation and support.
[17]
[18]
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